NURSING 201 Integrated Process - Nursing Process-Data Collection.

The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a) The client who requires a bed bath b) An older client requiring frequent ambulation c) A client who requires a 24-hour urine collection * d) A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours R: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. 2. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child that was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as a) G = 3, T = 2, P = 0, A = 0, L = 1 * b) G = 2, T = 1, P = 0, A = 0, L = 1 c) G = 1, T = 1, P = 1, A = 0, L = 1 d) G = 2, T = 0, P = 0, A = 0, L = 1 R: Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies. T is term births, the number born at term (longer than 37 weeks), P is preterm births, the number born before 37 weeks’ gestation, A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks’ gestation; included in parity if past 20 weeks’ gestation), and L is the number of current living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1 and the number of preterm births is 0. The number of abortions is 0 and the number of living children is 1. 3. The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a registered nurse, a licensed practical (vocational) nurse, and two nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a) The client who requires a 24-hour urine collection b) An elderly client requiring assistance with a bed bath and frequent ambulation c) A client on a mechanical ventilator requiring frequent assessment and suctioning * d) A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours R: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine and frequent ambulation can most appropriately be provided by the nursing assistant, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the registered nurse.